The Pathophysiology and Treatment

of Hereditary Tyrosinemia Type 1

Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
Markus Grompe, M.D.1

ABSTRACT

The topic of this review is hepatorenal tyrosinemia (hereditary tyrosinemia type

1 [HT1], or fumarylacetoacetate hydrolase deficiency; OMIM# 276700). HT1 is the
most serious and common of the genetic defects in tyrosine degradation. In addition, this
disorder has importance as a model of spontaneous self-correction of liver disease, as a
model of liver repopulation by transplanted cells and gene therapy, and as a genetic cause
of hepatocarcinoma. However, other forms of hypertyrosinemia exist; hence, the differen-
tial diagnosis also will be described briefly. Recent years have seen much progress in our
understanding of the molecular basis, the pathophysiology, and especially the treatment
of HT1. The current intervention with 2-(2-nitro-4-trifluoro-methylbenzyol)-1,3 cyclo-
hexanedione (NTBC) therapy has improved the outcome of this once devastating disor-
der. The successful repopulation of the HT1 liver with transplanted cells and positive re-
sults in the use of gene therapy in animal models may someday lead to therapy in humans
that will obviate the need for life-long dietary and pharmacological therapy.

KEYWORDS: Tyrosinemia, succinylacetone, hepatocarcinoma therapy

Objectives: Upon completion of this article the reader should be able to (1) describe the differential diagnosis of hypertyrosinemia,
(2) list the therapeutic approaches in hepatorenal tyrosinemia, and (3) describe the pathophysiology of hepatorenal tyrosinemia.
Accreditation: Tufts University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to
provide continuing medical education for physicians. TUSM takes full responsibility for the content, quality, and scientific integrity of
this continuing education activity.
Credit: Tufts University School of Medicine designates this education activity for a maximum of 1.0 hour credit toward the AMA
Physicians Recognition Award in category one. Each physician should claim only those hours that he/she actually spent in the edu-
cational activity.

I mpaired degradation of the aromatic amino
acid tyrosine is a feature of several acquired and genetic
liver disorders. In humans, hypertyrosinemia is defined
by elevated blood levels of >200 M.1 In mammals, ty-
rosine is both ketogenic and glucogenic. Its degradation
is catalyzed by a series of five enzymatic reactions
(Fig. 1) yielding acetoacetate (ketogenic) and the Krebs
cycle intermediate fumarate (glucogenic). Only two cell
types, the hepatocyte and renal proximal tubules, ex-
press the complete pathway and contain sufficient
quantities of all the enzymes required for tyrosine ca-
tabolism. Autosomal-recessive enzyme deficiency dis-
eases have been described for four of the five degrada-
tion steps, but not all of these result in elevated blood
tyrosine levels. Only one of these disorders, hereditary
tyrosinemia type 1 (HT1) causes liver disease and

Seminars in Liver Disease, volume 21, number 4, 2001. Address for correspondence and reprint requests: Markus Grompe, M.D., Department of
Molecular and Medical Genetics, L103, Oregon Health Sciences University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97201. E-mail:
grompem@ohsu.edu. 1Department of Molecular and Medical Genetics, Oregon Health Sciences University, Portland, Oregon. Copyright
2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0272-8087,p;2001,21,04,
563,572,ftx,en;sld00145x.
563
564 SEMINARS IN LIVER DISEASE/VOLUME 21, NUMBER 4 2001

Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
Figure 1 The mammalian tyrosine catabolic pathway. TAT, tyrosine amino transferase; HPD, 4-hydroxyphenylpyruvate dioxygenase;
HGD, homogentisic acid dioxygenase; MAI, maleylacetoacetate isomerase; FAH, fumarylacetoacetate hydrolase; FAR, fumarylace-
toacetate reductase; HT1, hereditary tyrosinemia type 1. The enzymatic reactions deficient in this disease are indicated by the hori-
zontal bar. NTBC, 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione.

therefore will be the main focus of this review. The
reader is referred elsewhere1 for details on the other dis-
orders of tyrosine degradation. The most common form
of tyrosinemia is transient tyrosinemia of the newborn,
which is particularly common in premature infants and
results from delayed maturation of the tyrosine metabo-
lizing enzymes.2 Elevated blood tyrosine is also found
in scurvy and many forms of both acute and chronic ac-
quired liver disease.
DIAGNOSIS AND
DIFFERENTIAL DIAGNOSIS OF
HYPERTYROSINEMIA
To detect elevated blood tyrosine levels, quantitative
measurement of plasma amino acids is required. This
test is usually performed to rule out metabolic liver dis-
ease or to evaluate possible metabolic etiologies in a
child with developmental delay. In some situations, ele-
vated blood tyrosines are discovered because of elevated
 HEREDITARY TYROSINEMIA/GROMPE 565

Table 1 Etiology of Elevated Blood Tyrosine Levels ACQUIRED TYROSINEMIA

1. Hepatocellular dysfunction
Increased blood tyrosine levels most commonly have
2. Transient tyrosinemia of the newborn
nongenetic origins. Elevated tyrosine per se does not
3. Genetic enzyme deficiencies in tyrosine degradation
cause any disease when the blood levels remain below
Hepatorenal tyrosinemia (HT1)
500 M, and hypertyrosinemia is therefore more of di-
Oculocutaneous tyrosinemia (HT2)
agnostic interest than of therapeutic concern.
4-OH-phenylpyruvate dioxygenase deficiency (HT3)
The most common noninherited cause of in-

4. Miscellaneous
Scurvy
Hyperthyroidism
Postprandial sample
NTBC therapy
tyrosine in a urine metabolic screen (renal Fanconi syn-
drome). The genetic and acquired disorders that can
lead to tyrosinemia are listed in Table 1. The main clin-
ical manifestations of hereditary disorders in tyrosine
degradation are listed in Table 2. The presence or ab-
sence of liver disease is the most important considera-
tion for both diagnosis and treatment. If liver disease is
present, additional diagnostic tests are urgently needed
to determine whether the patient has hepatorenal ty-
rosinemia (fumarylacetoacetate hydrolase deficiency is
the equivalent of tyrosinemia type 1). These tests in-
clude measurement of plasma levels of !-fetoprotein
(AFP) and the analysis of urine organic acids to check
for the presence succinylacetone, a hallmark metabolite
of this disease.
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
creased blood tyrosine levels is transient tyrosinemia of
the newborn.1,2 This condition is due to immaturity
of the liver and the enzymes involved in tyrosine degra-
dation. Historically, transient tyrosinemia was a com-
mon finding, but it has become much more rare with
modern neonatal management. When present it re-
sponds rapidly to pharmacological doses of vitamin C.
Hepatocellular dysfunction of any cause can re-
sult in elevated blood tyrosine and excretion of in-
creased amounts of tyrosine metabolites in urine. The
tyrosine levels are usually under 500 M, similar to
what is seen in hereditary tyrosinemia type 1. For this
reason, measurement of AFP levels and urinary suc-
cinylacetone are mandatory in this setting.
TYROSINEMIA TYPE 1
Clinical Manifestations
The natural history of HT1 is characterized by severe
liver disease, which frequently results in death. Symp-
toms can present early in infancy with an acute rapid
course, or they may progress more chronically.3 Interest-

Table 2 Clinical Manifestations of Enzyme Deficiencies in Tyrosine Catabolism

Elevated Renal
Defective Blood Corneal Hyper- Mental Liver Fanconi
Enzyme Disease Names Tyrosine Ulcers keratosis Retardation Arthritis Failure Syndrome

Tyrosine Tyrosinemia type II +++ +++ ++ +/"

aminotransferase Oculocutaneous
tyrosinemia
Richner-Hanhardt
syndrome
4-OH- Tyrosinemia type III ++ +/" +/" +/"
phenylpyruvate
dioxygenase
Homogentisate Alkaptonuria +++
dioxygenase
Maleylacetoacetate No human patients ? ? ? ? ? ? ?
isomerase described
Fumarylacetoacetate Tyrosinemia type I ++ +++ ++
hydrolase Hepatorenal
tyrosinemia
, symptom absent; +/", symptom present in some patients; +, ++, +++, symptom always present, ranging from mild (+) to moderate
(++) to severe (+++).
566 SEMINARS IN LIVER DISEASE/VOLUME 21, NUMBER 4 2001
ingly, the acute and chronic forms of the disease can
occur within the same sibship. Most patients present
with failure to thrive and hepatomegaly. The liver disease
is progressive, causing micro- and macronodular cirrho-
sis.4 Icterus, ascites, and hemorrhage often ensue. Pa-
tients also display renal tubular acidosis of the Fanconi
type, and typical radiographic changes of rickets are often
present. Mental retardation is not a feature. Surviving pa-
tients have a high risk for developing hepatocarcinoma.4
Porphyria-like neurologic crises are common in
poorly controlled HT1 and can be a major cause of
morbidity and mortality.5 The attacks can present as
pain, obtundation, and progressive paralysis, similar to
classic acute intermittent porphyria.
Laboratory Diagnosis
Biochemical alterations include elevated plasma con-
centrations of tyrosine and methionine, as well as the
excretion of tyrosyl compounds in the urine. The pres-
ence of succinylacetone in urine is diagnostic; therefore,
urine organic acid analysis is the single most important
diagnostic test for this disease. Highly elevated concen-
trations of AFP are seen, even before the elevation in
tyrosine. Hypoglycemia may occur, and coagulation de-
fects are common. Plasma transaminase levels (ALT
and AST) may be only mildly elevated and are in dis-
proportion to the degree of coagulopathy.6
Fumarylacetoacetate hydrolase (FAH) enzyme
activity can be measured in cultured skin fibroblasts or
liver specimens to confirm the diagnosis.
Genetics and Prenatal Diagnosis
Hereditary tyrosinemia type 1 is a common inborn error
of metabolism in some ethnic groups, most notably in
the population of the Lac-St. Jean region of Qubec,
where the frequency of heterozygotes has been esti-
mated to be 7%.7 The human FAH cDNA has been
cloned8 and mapped to human chromosome 15q,8 and
the gene structure has been elucidated.9 The human
FAH cDNA consists of 419 amino acids encoded by a
1,260-bp mRNA. The gene is approximately 35 kbp in
size and consists of 14 exons. DNA-based prenatal di-
agnosis and carrier detection are available, and the com-
mon mutations responsible for the ethnic clustering of
HT1 in French Canada and Scandinavia have been
identified.10,11
The French Canadian HT1 founder mutation is
a single base change in intron 12 (IVS12 + 5 g a),
which profoundly alters mRNA splicing and results in
the absence of hepatic enzyme activity. In Qubec this
allele is found on more than 95% of HT1 chromo-
somes, and this mutation is also the most common one
worldwide, accounting for about one third of all muta-
tions.11 A simple polymerase chain reaction (PCR)-
based method for the detection of IVS12 + 5 g a has
been developed and could be applied to population
screening. Another splice mutation, IVS6-1 g t, is
also fairly common and has been found in several popu-
lations. The Finnish HT1 founder mutation (W262X)
is a missense change.10 An up-to-date listing of known
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
FAH mutations can be found at the Human Gene Mu-
tation Database Web site (archive.uwcm.ac.uk/uwcm/
mg/search/119901.html).
Prenatal diagnosis for HT1 can be made using a
variety of methods. The presence of succinylacetone in
amniotic fluid is a fairly reliable indicator of the disease,
but false-negative results have been reported.12,13 The
FAH enzyme also can also be measured directly in cul-
tured amniocytes.14 Today, accurate DNA-based diag-
nosis is possible using both linkage analysis or direct
mutation detection.15 The human FAH gene has several
intragenic polymorphic markers, making linkage analy-
sis feasible in most cases.1619
Newborn Screening
Newborn screening for HT1 is performed in some re-
gions, particularly the Canadian province of Qubec,
where the disease is common.20,21 With the availability
of effective therapy, early identification of affected chil-
dren can prevent the evolution of severe liver disease
and greatly improve outcome.
Treatment
The classic dietary treatment of tyrosinemia type 1
consisted of dietary restriction of phenylalanine and ty-
rosine,22 but this regimen did not prevent progression of
the disease. Liver transplantation has been successfully
used in many patients.2325 The beneficial effects of liver
transplantation strongly suggest that expression of a
normal cDNA in hepatocytes of patients would allevi-
ate the defect; therefore, HT1 is a candidate disorder for
gene therapy directed at the liver.26
NTBC
The history of the discovery of 2-(2-nitro-4-trifluoro-
methylbenzyol)-1,3 cyclohexanedione (NTBC) as the
treatment for HT1 is an interesting saga. The class of
compounds to which NTBC belongs was developed in
the 1980s as a bleaching herbicide by the British phar-
maceutical company ICN-Zeneca. During small animal
toxicology studies, it was noted that treated rats devel-
oped corneal ulcerations, a hallmark of elevated blood
tyrosine in both rats and humans. It was then found
that NTBC and similar compounds are potent in-
hibitors of 4-OH phenylpyruvate dioxygenase (HPD),

the second step in tyrosine catabolism (Fig. 1). Inhibi-
tion of this enzyme is also the mechanism by which
benzoyl-cyclo-hexane-1,3-diones act as herbicides be-
cause plants need homogentisic acid as precursors for
chlorophyll biosynthesis.27 A weaker analogue is cur-
rently marketed as an herbicide under the brand name
Mikado (Bayer, Leverkusen, Germany).
In 1992, Lindstedt, Holme, and co-workers re-
alized NTBCs potential for the treatment of human
tyrosinemia and used it successfully in five patients.28
The principal underlying this treatment is to reduce
metabolic flow through the tyrosine catabolic pathway
and to prevent the formation of the toxic compounds
maleylacetoacetate (MAA) and fumarylacetoacetate
(FAA) (Fig. 1). In the most recently published study,
over 300 patients worldwide have received this treat-
ment, and in most patients (>95%) liver functions im-
proved rapidly. This represents a significant improve-
ment over historical controls, so NTBC currently is
the clear treatment of choice for HT1. Kidney func-
tion is also significantly improved by the drug, and
renal Fanconi syndrome is avoided. A large number of
patients has now been treated for more than 5 years,
and significant side effects of NTBC have not been
reported. At this writing, NTBC is still an investiga-
tive drug, but is available through research protocols in
the United States (crscott@u.washington.edu), Canada
(mitchell@justine.umontreal.ca), and Europe (elisa-
beth.holme@ clinchem.gu.se). NTBC is given twice
daily orally at a typical starting dose of 1 mg/kg/day.
Because NTBC increases blood tyrosine levels, pa-
tients also need to be kept on a protein-restricted diet
that is low in phenylalanine and tyrosine. Effective
management and adjustment of the dose requires fre-
quent metabolic monitoring, including the measure-
ment of plasma amino acids, blood and urinary suc-
cinylacetone, liver function tests, and plasma AFP. The
latter is particularly important because a small per-
centage of late-treated patients developed hepatocellu-
lar carcinoma despite NTBC treatment.29 Blood tyro-
sine levels should be kept under 500 M. Routine
ophthalmologic examination and hepatic imaging are
also recommended. Despite the clear benefits of
NTBC therapy, there are concerns about its effects
when used long term. First, some patients have devel-
oped hepatic cancer while on therapy. Second, all
known patients with inherited HPD deficiency have
neurologic problems.30,31 Mental retardation is also
found in 50% of tyrosinemia type II patients.32 Thus,
long-term follow-up studies will be required before
the safety of this approach is fully established.
For those patients who do not respond to NTBC
therapy or have evidence of hepatic malignancy, ortho-
topic liver transplantation remains the treatment of
choice.
HEREDITARY TYROSINEMIA/GROMPE 567
Somatic Mosaicism and Liver Repopulation
in Hereditary Tyrosinemia
In 1993 an unusual observation was made in human
patients with HT1: patient livers were removed at the
time of liver transplantation and multiple large and
small nodules were found as is typical in HT1. An im-
munohistological analysis with FAH antibody was
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
performed, and, surprisingly, the livers represented a
mosaic of antibody positive and negative hepatic tis-
sue.33 FAH enzyme activity was present in the cross-
reacting material-positive nodules, and molecular
analysis has revealed they were generated by somatic
reversion of the disease causing inherited mutation34
followed by clonal selection of reverted hepatocytes.
This observation demonstrated the strong selective
growth advantage of spontaneously reverted FAH-
positive hepatocytes in this disease. Human HT1 thus
provided the first example of spontaneous gene ther-
apy in the liver. Interestingly, mutation reversion has
been observed not only in compound heterozygotes, in
whom intragenic mitotic recombination could result in
restoration of enzyme activity. Reversions also have
been found in patients homozygous for the same mu-
tant allele on both chromosomes.35 This phenomenon
requires precise removal of the single base change mu-
tation responsible for the disease.
In most patients the amount of reverted tissue is
too low to result in a cure of the disease, but it seems
likely that some of the intrafamilial variability in the clin-
ical course of HT1 may be due to somatic mosaicism.35
Patients with a significant mass of reverted hepatocytes
may have a milder form of the disease. This hypothesis
has not yet been directly confirmed in humans, but ani-
mal experiments indicate that partial reconstitution by
FAH-positive hepatocytes can be therapeutic.36
Biochemistry of FAH
The mammalian tyrosine catabolic pathway was worked
out in the early 1950s by Edwards and Knox.3739 The
FAH enzyme assay first described then is still used
today. FAA is considered the natural substrate of FAH,
but the enzyme also uses succinylacetoacetate (SAA) as
a substrate (Fig. 1), and both FAA and SAA accumu-
late in FAH deficiency. The mechanism of the reduc-
tion of FAA to SAA has not been established, but it
is likely catalyzed by a yet uncharacterized enzyme,
FAA-reductase.
Human wild-type FAH has a Km for FAA of
!3.5 M. It is cytosolic and acts as a homodimer with a
molecular weight of approximately 80 kDa. Recently,
the crystal structure of FAH has been determined.40
The detailed topography of the active site was con-
firmed by the development of an FAH inhibitor and
cocrystallization of this molecule with the enzyme.41
568 SEMINARS IN LIVER DISEASE/VOLUME 21, NUMBER 4 2001
Pathophysiology
The discussion of the pathophysiology of HT1 will be
grouped by the main findings of the disorder.
ELEVATED BLOOD TYROSINE
In 1977 it was discovered that HT1 is caused by a defi-
ciency of FAH, the last enzyme in tyrosine catabo-
lism.42 This was surprising because FAH is five steps re-
moved from the initial metabolism of tyrosine, and
enzyme deficiency would not be expected to result in el-
evated blood tyrosine. Furthermore, deficiency of ho-
mogentisic acid dioxygenase, the third enzyme of the
degradation cascade, is not associated with hyperty-
rosinemia.43 Indeed, the elevated blood tyrosine levels
in HT1 are due to a secondary inhibition of proximal
steps in tyrosine degradation and not the lack of FAH
itself. In FAH mutant mice, the mRNA for tyrosine
amino transferase (TAT), the rate-limiting enzyme in
tyrosine degradation, is absent. The activity of HPD is
also decreased in human HT1 liver.
Importantly, tyrosine per se is not toxic to the
liver or kidney, but rather causes only dermatological,
ophthalmologic, and possibly neurodevelopmental
problems.1 Patients with tyrosinemia type 2 (TAT defi-
ciency, Richner-Hanhardt syndrome) and type 3 (PPD
deficiency) have highly elevated blood tyrosine levels
but do not manifest liver disease or renal tubular
dysfunction.4447
LIVER INJURY
Fumarylacetoacetate, the compound that accumulates
in FAH deficiency, is a potent alkylator, causing oxida-
tive damage to the cells in which it is generated by re-
acting with glutathione and sulfhydryl groups of pro-
teins. Importantly, FAA acts cell autonomously, directly
damaging only the hepatocytes and renal proximal
tubules in which it is produced and not adjacent cells.48
Because of its rapid reactivity, FAA itself is not found in
body fluids of HT1 patients. SAA and succinylacetone
(SA) derived from reduction of FAA are the principal
metabolites of FAA (Fig. 1). These compounds are
found systemically, and testing for them diagnostically
is routine.
The accumulation of FAA within the hepatocyte
results in one of two outcomes: (a) apoptotic cell death
or (b) a profound perturbation of gene expression. Re-
cent studies have shown that acute accumulation of
FAA triggers apoptosis in both hepatocytes and renal
tubular cells.49,50 Apoptosis is mediated by caspases
1 and 3 and is associated with cytochrome c release.51
Glutathione is protective, and its intracellular level
can clearly modulate the threshold for FAA-induced
apoptosis.51
Hepatocytes can survive with FAH deficiency, if
the substrate accumulation is more gradual, but mutant
cells display a striking disregulation of gene expression.
This phenomenon was intensely studied in the lethal al-
bino mouse, an animal model of FAH deficiency. In
these mice, many hepatic enzymes and proteins are ex-
pressed abnormally or not at all. Interestingly, all tran-
scripts regulated by glucocorticoids via cyclic AMP are
severely downregulated. These include TAT,52 glucose-6
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
phosphatase (G-6P),53 and phosphoenolpyruvate car-
boxykinase (PEPCK).54 Other affected genes are gluta-
mine synthetase (GS),53 aldolase B, and albumin.55,56 As
a result, many metabolic processes are negatively af-
fected, including gluconeogenesis, ammonia detoxifica-
tion, and synthesis of secreted proteins. Other liver
mRNAs are increased in HT1 hepatocytes, and these
include genes inducible by DNA or oxidative damage
such as CHOP and NMO-1.57,58 The detailed mecha-
nism by which FAH deficiency causes misexpression of
genes is not yet understood. However, FAA acts via the
electrophile response element (EPRE) DNA motif59
and induces phase II dioxin-inducible (Ah) genes.60
Thus, the perturbed gene expression can be viewed as a
protective response against severe oxidative stress.
RENAL TUBULAR INJURY
Fumarylacetoacetate hydrolase deficiency can cause di-
rect injury in renal proximal tubular cells, and FAA has
induced apoptosis acutely, just as in hepatocytes.50
However, some of the kidney phenotype is mediated by
circulating succinylacetone. This compound can induce
renal Fanconi syndrome by itself when injected into
normal rats.61,62 Because SA is responsible for this phe-
notype, the normalization of SA blood levels by liver
transplantation also abrogates the renal tubular acidosis.
Thus, the renal pathology in HT1 appears to be largely
noncell autonomous.
HEPATOCARCINOMA
The evolution of hepatocarcinoma in human HT1 pa-
tients has not been studied in detail to determine
whether it differs from hepatocarcinoma of other
causes. However, it is known that FAA is strongly mu-
tagenic. The mutagenicity of FAA has been docu-
mented both in vitro63 and in vivo.64 The mutation
spectrum induced by FAA in vivo in mouse hepatocytes
has been studied in some detail. Surprisingly FAA in-
duces not only point mutations (!20%), but small in-
sertions and deletions (!30%) and large genomic re-
arrangements (!50%).64 The precise mechanism by
which FAA causes mutations is not known. It may react
and damage (alkylate) DNA directly, in which case
point mutations would be the most expected result. Al-
ternatively, FAA may act indirectly by damaging cellular
proteins involved in maintaining genomic stability. This
mechanism would provide a better explanation for the
mutational spectrum seen in vivo.

NEUROLOGICAL CRISIS
Several remarkable secondary biochemical alterations
have been described in HT1. The most prominent is the
inhibitory effect of SA on !-aminolevulinic acid dehy-
dratase, the first step of heme biosynthesis.65 This leads
to neurologic crisis, as seen in acute intermittent por-
phyria.5 NTBC treatment blocks the accumulation of
SA and therefore also prevents neurologic crises.
Model Systems
The tyrosine catabolic pathway is conserved in many
eukaryotes, including the fungus Aspergillus nidulans,
which has emerged as a important model system. Mod-
els of FAH deficiency have been engineered in the
mouse and in aspergillus.
THE C14CoS LETHAL ALBINO MUTANT MOUSE
The c14CoS albino mouse is one of a series of mutant
mice bearing large overlapping x-rayinduced deletions
of chromosome 7.53,66 All albino deletions are estimated
to be several megabases in size,67 but show substantial
overlap. Mice homozygous for the deletions c65kb, c112Kb,
c3H, and c14CoS die within a few hours after birth and
display a striking biochemical phenotype. Profound ab-
normalities are found in both liver and kidney in these
mice, and because of this downregulation of multiple
liver enzymes in the homozygous deletion, it was hy-
pothesized that a regulatory liver gene (hepatocyte-
specific developmental regulation locus, or hsdr-1) was
localized within the region.56 Detailed mapping of the
deletion intervals revealed that the hsdr-1 gene was
identical to FAH.48 This was confirmed by the fact that
FAH knockout mice had very similar hepatic pheno-
types to c14CoS albino mice. Hence, the profound disreg-
ulation of hepatic gene expression in this model can be
ascribed completely to the metabolic effects of FAA
accumulation.
FAH#exon 5 Knockout Mice
Another model of FAH deficiency in the mouse was
generated by targeted disruption of exon 5 of the gene
in embryonic stem cells.68 Homozygotes had a pheno-
type identical to lethal albino mice and died in the new-
born period. Fortunately, NTBC also worked in mice
and can be used to rescue FAH mutant mice.69 NTBC-
treated FAH#exon5 animals can be maintained for more
than 1 year without liver disease and are fertile.70 This
strain of mice has become one of the main models for
liver repopulation by genetically modified hepato-
cytes36,7173 or cell transplantation.7476 FAH-positive
hepatocytes have a strong selective advantage in the set-
ting of a tyrosinemic liver similar to that seen in human
patients.33 The strong selection in this model also has
HEREDITARY TYROSINEMIA/GROMPE 569
led to the recent discovery of extrahepatic liver stem
cells in the pancreas and bone marrow.77,78
Therapeutic liver repopulation has been the sub-
ject of recent reviews, to which the reader is referred for
further details.79,80
FAH-DEFICIENT FUNGUS
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
A strain of FAH-deficient Aspergillus nidulans has been
instrumental in the study of tyrosine catabolism81 and
therefore will be mentioned here. Two of the genes in
the pathway (HGD and MAI) were first cloned in this
organism, and only then were then the human genes
found.82,83 The molecular basis of alkaptonuria, the first
human recessive disease described,84 was discovered
based on experiments performed in this system.85
ABBREVIATIONS
AFP !-fetoprotein
EPRE electrophile response element
FAA fumarylacetoacetate
FAH fumarylacetoacetate hydrolase
G-6P glucose-6 phosphatase
GS glutamine synthetase
HT1 hereditary tyrosinemia type 1
NTBC 2-(2-nitro-4-trifluoro-methylbenzyol)-1,3
cyclohexanedione
PEPCK phosphoenolpyruvate carboxykinase
PPD phenylpyruvate dioxygenase
SA succinylacetone
SAA succinylacetoacetate
TAT tyrosine amino transferase
REFERENCES
1. Mitchell GA, Grompe M, Lambert M, et al. Hypertyrosine-
mia. In: Scriver CR, Beaudet AL, Sly W, Valle D, eds. The
Metabolic and Molecular Basis of Inherited Disease, 9th ed.
New York: McGraw-Hill, 2001:17771805
2. Levine SZ, Marples E, Gordon HH. A defect in the metabo-
lism of aromatic amino acids in premature infants: The role of
vitamin C. Science 1939;90:620
3. Kvittingen E. Hereditary tyrosinemia type Ian overview.
Scand J Clin Lab Invest 1986;46:2734
4. Russo P, ORegan S. Visceral pathology of hereditary tyrosine-
mia type I. Am J Hum Genet 1990;47:317324
5. Mitchell G, Larochelle J, Lambert M, et al. Neurologic crises
in hereditary tyrosinemia. N Engl J Med 1990;322:432437
6. Croffie JM, Gupta SK, Chong SK, et al. Tyrosinemia type 1
should be suspected in infants with severe coagulopathy even
in the absence of other signs of liver failure. Pediatrics 1999;
103:675678
7. De Braekeleer M, Larochelle J. Genetic epidemiology of he-
reditary tyrosinemia in Quebec and in Saguenay-Lac-St-Jean.
Am J Hum Genet 1990;47:302307
8. Phaneuf D, Labelle Y, Brub D, et al. Cloning and expression
of the cDNA encoding human fumarylacetoacetae hydrolase,
the enzyme deficient in hereditary tyrosinemia: assignment of
570 SEMINARS IN LIVER DISEASE/VOLUME 21, NUMBER 4 2001
the gene to chromosome 15. Am J Hum Genet 1991;48:
525535
9. Labelle Y, Phaneuf D, Leclerc B, et al. Characterization of
the human fumarylacetoacetate hydrolase gene and identifi-
cation of a missense mutation abolishing enzymatic activity.
Hum Mol Genet 1993;2:941946
10. St-Louis M, Leclerc B, Laine J, et al. Identification of a stop
mutation in five Finnish patients suffering from hereditary
tyrosinemia type I. Hum Mol Genet 1994;3:6972
11. Grompe M, St-Louis M, Demers SI, et al. A single mutation
of the fumarylacetoacetate hydrolase gene in French Canadi-
ans with hereditary tyrosinemia type I. N Engl J Med 1994;
331:353357
12. Jakobs C, Stellaard F, Kvittingen EA, et al. First-trimester
prenatal diagnosis of tyrosinemia type I by amniotic fluid suc-
cinylacetone determination. Prenat Diagn 1990;10:133134
13. Grenier A, Cederbaum S, Laberge C, et al. A case of tyrosi-
naemia type I with normal level of succinylacetone in the am-
niotic fluid. Prenat Diagn 1996;16:239242
14. Kvittingen EA, Steinmann B, Gitzelmann R, et al. Prenatal
diagnosis of hereditary tyrosinemia by determination of fu-
marylacetoacetase in cultured amniotic fluid cells. Pediatr Res
1985;19:334337
15. Demers SI, Phaneuf D, Tanguay RM. Hereditary tyrosinemia
type I: strong association with haplotype 6 in French Canadi-
ans permits simple carrier detection and prenatal diagnosis.
Am J Hum Genet 1994;55:327333
16. Rootwelt H, Kvittingen EA, Hoie K, et al. The human fu-
marylacetoacetase gene: characterisation of restriction frag-
ment length polymorphisms and identification of haplotypes
in tyrosinemia type 1 and pseudodeficiency. Hum Genet
1992;89:229233
17. Demers SI, Phaneuf D, Tanguay RM. TaqI RFLP for the
human fumarylacetoacetate hydrolase (FAH) gene. Nucleic
Acids Res 1991;19:1352
18. Demers SI, Tanguay RM. MspI RFLP in the human fumary-
lacetoacetate hydrolase (FAH) gene. Nucleic Acids Res 1991;
19:6971
19. Demers SI, Tanguay RM. Bg1II RFLP for the human fu-
marylacetoacetate hydrolase (FAH) gene. Nucleic Acids Res
1991;19:1965
20. Hutchesson AC, Hall SK, Preece MA, Green A. Screening
for tyrosinaemia type I. Arch Dis Child Fetal Neonatal Ed
1996;74:F191F194
21. Belanger M, Saint HB, Belanger L. A system of early screen-
ing for inborn errors of metabolism: methods and results for
hereditary tyrosinemia. Union Med Can 1973;102:294302
22. Bain MD, Purkiss P, Jones M, et al. Dietary treatment elimi-
nates succinylacetone from the urine of a patient with ty-
rosinemia type I. Eur J Pediatr 1990;149:637639
23. Murcia FJ, Vazquez J, Gamez M, et al. Liver transplantation
in type I tyrosinemia. Transplant Proc 1995;27:23012302
24. Esquivel CO, Mieles L, Marino IR, et al. Liver transplanta-
tion for hereditary tyrosinemia in the presence of hepatocel-
lular carcinoma. Transplant Proc 1989;21:24452446
25. van Thiel DH, Gartner LM, Thorp FK, et al. Resolution of
the clinical features of tyrosinemia following orthotopic liver
transplantation for hepatoma. J Hepatol 1986;3:4248
26. Horwich AL. Inherited hepatic enzyme defects as candidates
for liver-directed gene therapy. Curr Top Microbiol Immunol
1991;168:185200
27. Lock EA, Ellis MK, Gaskin P, et al. From toxicological prob-
lem to therapeutic use: the discovery of the mode of action of
2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione
(NTBC), its toxicology and development as a drug. J Inherit
Metab Dis 1998;21:498506
28. Lindstedt S, Holme E, Lock EA, et al. Treatment of heredi-
tary tyrosinaemia type I by inhibition of 4-hydroxyphenyl-
pyruvate dioxygenase. Lancet 1992;340:813817
29. Holme E, Lindstedt S. Tyrosinaemia type I and NTBC (2-
(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione). J
Inherit Metab Dis 1998;21:507517
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
30. Origuchi Y, Endo F, Kitano A, et al. Sural nerve lesions in a
case of hypertyrosinemia. Brain Dev 1982;4:463
31. Giardini O, Cantani A, Kennaway NG, et al. Chronic ty-
rosinemia associated with 4-hydroxyphenylpyruvate dioxyge-
nase deficiency with acute intermittent ataxia and without
visceral and bone involvement. Pediatr Res 1983;17:2529
32. Fois A, Borgogni P, Cioni M, et al. Presentation of the data of
the Italian registry for oculocutaneous tyrosinaemia. J Inherit
Metab Dis 1986;9:262
33. Kvittingen EA, Rootwelt H, Brandtzaeg P, et al. Hereditary
tyrosinemia type I. Self-induced correction of the fumary-
lacetoacetase defect. J Clin Invest 1993;91:18161821
34. Kvittingen EA, Rootwelt H, Berger R, et al. Self-induced
correction of the genetic defect in tyrosinemia type I. J Clin
Invest 1994;94:16571661
35. Poudrier J, Lettre F, Scriver CR, et al. Different clinical forms
of hereditary tyrosinemia (type I) in patients with identical
genotypes. Mol Genet Metab 1998;64:119125
36. Overturf K, Al-Dhalimy M, Tanguay R, et al. Hepatocytes
corrected by gene therapy are selected in vivo in a murine
model of hereditary tyrosinaemia type I. Nat Genet 1996;12:
266273
37. Knox WE, Edwards SW. Enzymes involved in conversion of
tyrosine to acetoacetate. Methods Enzymol 1955;2:287300
38. Edwards SW, Knox WE. Homogentisate metabolism: the iso-
merization of maleylacetoacetate by an enzyme which requires
glutathione. J Biol Chem 1956;220:79
39. Knox WE, Edwards SW. Homogentisate oxidase of liver. J
Biol Chem 1955;216:479487
40. Timm DE, Mueller HA, Bhanumoorthy P, et al. Crystal
structure and mechanism of a carbon-carbon bond hydrolase.
Structure Fold Des 1999;7:10231033
41. Bateman RL, Bhanumoorthy P, Witte JF, et al. Mechanistic
inferences from the crystal structure of fumarylacetoacetate
hydrolase with a bound phosphorus-based inhibitor. J Biol
Chem 2001;276:1528415291
42. Lindblad B, Lindstedt S, Steen G. On the enzymic defects in
hereditary tyrosinemia. Proc Natl Acad Sci USA 1977;74:
46414645
43. La Du BN, Zannoni VG, Laster L, et al. The nature of the
defect in tyrosine metabolism in alkaptonuria. J Biol Chem
1958;230:251260
44. Rehak A, Selim MM, Yadav G. Richner-Hanhart syndrome
(tyrosinaemia-II) (report of four cases without ocular involve-
ment). Br J Dermatol 1981;104:469475
45. Bienfang DC, Kuwabara T, Pueschel SM. The Richner-
Hanhart syndrome: report of a case with associated tyrosine-
mia. Arch Ophthalmol 1976;94:11331137
46. Endo F, Katoh H, Matsuda I. Putative genetic deficiency of
4-hydroxyphenylpyruvic acid dioxygenase in mice: a murine
model for hereditary tyrosinaemia type III. J Inherit Metab
Dis 1990;13:780782
47. Cerone R, Holme E, Schiaffino MC, et al. Tyrosinemia type
III: diagnosis and ten-year follow-up. Acta Paediatr 1997;86:
10131015
48. Ruppert S, Kelsey G, Schedl A, et al. Deficiency of an en-

zyme of tyrosine metabolism underlies altered gene expres-
sion in newborn liver of lethal albino mice. Genes Dev
1992;6:14301443
49. Kubo S, Sun M, Miyahara M, et al. Hepatocyte injury in ty-
rosinemia type 1 is induced by fumarylacetoacetate and is in-
hibited by caspase inhibitors. Proc Natl Acad Sci USA 1998;
95:95529557
50. Sun MS, Hattori S, Kubo S, et al. A mouse model of renal tu-
bular injury of tyrosinemia type 1: development of de Toni
Fanconi syndrome and apoptosis of renal tubular cells in
Fah/Hpd double mutant mice. J Am Soc Nephrol 2000;11:
291300
51. Jorquera R, Tanguay RM. Cyclin B-dependent kinase and
caspase-1 activation precedes mitochondrial dysfunction in
fumarylacetoacetate-induced apoptosis. FASEB J 1999;13:
22842298
52. Schmid W, Mller G, Schtz G, et al. Deletions near the al-
bino locus on chromosome 7 of the mouse affect the level of
tyrosine aminotransferase mRNA. Proc Natl Acad Sci USA
1985;82:28662869
53. Gluecksohn-Waelsch S. Genetic control of morphogenetic
and biochemical differentiation: lethal albino deletions in the
mouse. Cell 1979;16:225237
54. Loose DS, Shaw PA, Krauter KS, et al. Trans regulation of
the phosphoenolpyruvate carboxykinase (GTP) gene, identi-
fied by deletions in chromosome 7 of the mouse. Proc Natl
Acad Sci USA 1986;83:51845188
55. Sala-Trepat JM, Poiret M, Sellem CH, Bessada R, et al. A
lethal deletion on mouse chromosome 7 affects regulation of
liver cell-specific functions: posttranscriptional control of
serum protein and transcriptional control of aldolase B syn-
thesis. Proc Natl Acad Sci USA 1985;82:24422446
56. Ruppert S, Boshart M, Bosch FX, et al. Two genetically de-
fined trans-acting loci coordinately regulate overlapping sets
of liver-specific genes. Cell 1990;61:895904
57. Fornace AJ Jr, Nebert DW, Hollander MC, et al. Mammalian
genes coordinately regulated by growth arrest signals and
DNA-damaging agents. Mol Cell Biol 1989;9:4196203
58. Petersen DD, Gonzalez FJ, Rapic V, et al. Marked increases
in hepatic NAD(P)H: oxidoreductase gene transcription and
mRNA levels correlated with a mouse chromosome 7 dele-
tion. Proc Natl Acad Sci USA 1989;86:66996703
59. Nebert DW, Roe AL, Dieter MZ, et al. Role of the aromatic
hydrocarbon receptor and [Ah] gene battery in the oxidative
stress response, cell cycle control, and apoptosis. Biochem
Pharmacol 2000;59:6585
60. Vasiliou V, Puga A, Chang CY, et al. Interaction between the
Ah receptor and proteins binding to the AP-1like electrophile
response element (EpRE) during murine phase II [Ah] battery
gene expression. Biochem Pharmacol 1995;50:20572068
61. Spencer PD, Roth KS. Effects of succinylacetone on amino
acid uptake in the rat kidney. Biochem Med Metab Biol
1987;37:101109
62. Spencer PD, Medow MS, Moses LC, et al. Effects of suc-
cinylacetone on the uptake of sugars and amino acids by
brush border vesicles. Kidney Int 1988;34:671677
63. Jorquera R, Tanguay RM. The mutagenicity of the tyrosine
metabolite, fumarylacetoacetate, is enhanced by glutathione
depletion. Biochem Biophys Res Commun 1997;232:4248
64. Manning K, Al-Dhalimy M, Finegold M, et al. In vivo suppres-
sor mutations correct a murine model of hereditary tyrosinemia
type I. Proc Natl Acad Sci USA 1999;96:1192811933
65. Sassa S, Kappas A. Succinylacetone inhibits delta-aminole-
vulinate dehydratase and potentiates the drug and steroid in-
HEREDITARY TYROSINEMIA/GROMPE 571
duction of delta-aminolevulinate synthase in liver. Trans
Assoc Am Physicians 1982;95:4252
66. Russell LB, Russell WL, Kelly EM. Analysis of the albino-
locus region of the mouse. Origin and viability. Genetics
1979;91:127139
67. Niswander L, Kelsey G, Schedl A, et al. Molecular mapping
of albino deletions associated with early embryonic lethality
in the mouse. Genomics 1991;9:162169
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.
68. Grompe M, Al-Dhalimy M, Finegold M, et al. Loss of fu-
marylacetoacetate hydrolase is responsible for the neonatal
hepatic dysfunction phenotype of lethal albino mice. Genes
Dev 1993;7:22982307
69. Grompe M, Lindstedt S, al-Dhalimy M, et al. Pharmacologi-
cal correction of neonatal lethal hepatic dysfunction in a
murine model of hereditary tyrosinaemia type I. Nat Genet
1995;10:453460
70. Grompe M, Overturf K, Al-Dhalimy M, et al. Therapeutic
trials in the murine model of hereditary tyrosinemia type I: a
progress report. J Inher Metab Dis 1998;21:518531
71. Overturf K, al-Dhalimy M, Ou CN, et al. Adenovirus-
mediated gene therapy in a mouse model of hereditary ty-
rosinemia type I. Hum Gene Ther 1997;8:513521
72. Overturf K, Al-Dhalimy M, Manning K, et al. Ex vivo he-
patic gene therapy of a mouse model of hereditary tyrosine-
mia type I. Hum Gene Ther 1998;9:295304
73. Chen SJ, Tazelaar J, Moscioni AD, et al. In vivo selection of
hepatocytes transduced with adeno-associated viral vectors.
Mol Ther 2000;1:414422
74. Overturf K, Al-Dhalimy M, Finegold M, et al. The repop-
ulation potential of hepatocyte populations differing in size
and prior mitotic expansion. Am J Pathol 1999;155:
21352143
75. Grompe M, Al-Dhalimy M, Overturf K, et al. Hepatic re-
population by adult murine pancreatic liver stem cells. Am J
Hum Genet 1998;63:9
76. Overturf K, Al-Dhalimy M, Ou CN, et al. Serial transplanta-
tion reveals the stem-celllike regenerative potential of adult
mouse hepatocytes. Am J Pathol 1997;151:12731280
77. Wang X, Al-Dhalimy M, Lagasse E, et al. Liver repopulation
and correction of metabolic liver disease by transplanted adult
mouse pancreatic cells. Am J Pathol 2001;158:571579
78. Lagasse E, Connors H, Al-Dhalimy M, et al. Purified
hematopoietic stem cells can differentiate into hepatocytes in
vivo. Nat Med 2000;6:12291234
79. Grompe M. Liver repopulation for the treatment of meta-
bolic diseases. J Inherit Metab Dis 2001;24:231244
80. Grompe M, Laconi E, Shafritz DA. Principles of therapeutic
liver repopulation. Semin Liver Dis 1999;19:714
81. Fernandez-Canon JM, Penalva MA. Fungal metabolic model
for human type I hereditary tyrosinaemia. Proc Natl Acad Sci
USA 1995;92:91329136
82. Fernandez-Canon JM, Penalva MA. Molecular characteriza-
tion of a gene encoding a homogentisate dioxygenase from
Aspergillus nidulans and identification of its human and plant
homologues. J Biol Chem 1995;270:2119921205
83. Fernandez-Canon JM, Penalva MA. Characterization of a
fungal maleylacetoacetate isomerase gene and identification
of its human homologue. J Biol Chem 1998;273:329337
84. Garrod AE. The incidence of alkaptonuria: a study in chemi-
cal individuality. Lancet 1902;2:16161620
85. Fernandez-Canon JM, Granadino B, Beltran-Valero de
Bernabe D, et al. The molecular basis of alkaptonuria. Nat
Genet 1996;14:1924
Downloaded by: IP-Proxy CONSORTIUM:Harrass (Oregon HealthScience Univ), Oregon Health and Science University. Copyrighted material.